Palliative care and assisted suicide:
the SICP Position Paper within the framework of the international scientific literature




COSIMO CHELAZZI, FURIO ZUCCO

1Associate Professor of Palliative Care, Università degli Studi di Brescia; Director of SC Cure Palliative e ADI, ASST Spedali Civili di Brescia; 2Senior Consultant Polis Accademia-Ente di Formazione-Regione Lombardia; President of OdV Presenza Amica per l’aiuto ai sofferenti.

Received on July 15, 2026

The World Health Organization defines palliative care as an approach that “affirms life and regards dying as a normal process” and that “intends neither to hasten or postpone death”1. This definition, constitutive of the professional identity of the discipline, opens a conceptual, ethical, and operational tension in relation to requests for medical assistance in dying (MAID) in countries where it has been legalized2.

This tension concerns three questions3. The first pertains to professional integrity: is including MAID within palliative care consistent with the discipline’s stated aims? The second concerns person-centredness: does denying any relationship between MAID and palliative care contradict the values of comprehensive care of suffering and of promoting the patient’s decisional autonomy? The third concerns the potential clinical benefit of palliative care: if the health professionals working within the teams refuse to take part in the decision-making process leading to the choice of MAID, how can it be ruled out that that patient’s palliative needs remain unmet? These questions are particularly relevant because, where provided for by health systems, MAID concerns in most cases people affected by an advanced life-limiting illness4, often in settings where a mature palliative care practice coexists2.

In Italy, with Constitutional Court judgment no. 242/2019 and subsequent rulings, the legal system has rendered assistance to suicide non-punishable under defined conditions, opening the way to MAID in the form of assisted suicide. Pending a national law, several Regions are adopting measures that make access more concrete for patients suffering from incurable diseases, granting access to the procedure to a small but steady number of patients.

In this context, in June 2026, the Italian Society of Palliative Care (SICP) published a Position Paper on the relationship between palliative care and assisted suicide5. The document distinguishes the two domains on the conceptual and ethical level and defines them as “two different answers to different questions”5.

In countries where MAID is legal, its stated purpose is to relieve the patient’s suffering, to promote their autonomy, and to preserve their dignity4: what distinguishes the two domains is the response to suffering. Indeed, where MAID is available, its relationship with palliative care is not uniform: it takes different and sometimes co-occurring forms, ranging from clear opposition to coexistence and even integration2.

In Belgium, where euthanasia has been legal since 2002 and palliative care is well developed, the two domains show a certain degree of operational overlap6. In a retrospective mortality follow-back survey conducted by questioning the certifying physicians of a sample of 6,871 deaths that occurred in Flanders in 2013, patients requesting euthanasia were found to have accessed palliative care more frequently than those who had died non-suddenly without making such a request (70.9% vs 45.2%; OR 2.1; 95% CI 1.5–2.9)6. Moreover, the involvement of palliative care did not reduce the probability that the request would be granted6.

In Switzerland, assisted suicide is mainly entrusted to right-to-die associations that seek to protect the autonomy to decide the timing of one’s own death, with medical involvement limited to prescribing the drug and certifying the eligibility requirements for the procedure. In a qualitative study of 23 Swiss palliative care physicians, all regularly received requests for assisted suicide despite having received no specific training7. Most had no relationship with the associations, tended to explore the reasons behind the request and to propose alternatives, and reported difficulty in reconciling the principles of palliative care with the patient’s will to self-determination7. In Canada, the relationship is integrated and collaborative in some services but remains evolving. In the United States, the documented experience concerns almost exclusively Oregon, where palliative care professionals often operate without a defined role in relation to MAID, in the absence of shared protocols2.

The multiplicity of observed practices corresponds to a plurality of ethical positions, on which the discipline of palliative medicine remains divided.

According to some, MAID does not fall within the scope of palliative care. In its 2016 white paper, developed through a Delphi consultation of experts from various European countries, the European Association for Palliative Care (EAPC) excludes it from palliative practice. Nevertheless, the paper acknowledges that palliative care should be offered to patients who request MAID8. Chochinov and Fins have recently expressed a more stringent position9. In their view, MAID would not constitute a therapeutic act, as it would not be “restorative,” being an irreversible solution and not “proportional” to a clinical aim: death cannot indeed be “titrated” against a need. As such, MAID could not be regarded as a medical or health-care practice and would therefore be considered extraneous to palliative care as well9.

According to others, the two domains are compatible, or at least not mutually exclusive. They share common ground: respect for autonomy and the relief of suffering. The choice to legalize MAID, moreover, is political and social rather than medical, and the divergence of positions is regarded as physiological within the discipline3,5. Three arguments are put forward in favour of compatibility. On the historical level, the boundary is not immutable: the withdrawal of life-sustaining treatments was in the past ascribed, in some jurisdictions, to homicide or MAID, only to be redefined over time, often at the impetus of patients10. On the philosophical level, the opposition of part of the palliative care community would reflect a “Hippocratic” medical paradigm, centred on the preservation of life, as opposed to a “Socratic medicine” grounded in self-determination11. On the ethical-clinical level, palliative care would be neither always available nor always effective, and a not fully controllable suffering, particularly existential, might persist in the patient12.

In contrast to these dichotomous views, the SICP Position Paper adopts an ethics of care grounded in non-abandonment and in safeguarding the freedom of the ill person, understood as the possibility of choosing in the absence of avoidable suffering, inadequate information, or inadequate care5. From this framework follows the procedural choice: the document recommends the presence of the palliative care team in the informative and evaluative phases of the request, while arguing for its institutional and binding exclusion from the implementation phase5. This is intended to assess the presence of suffering in the ill person and, at the same time, to be able to offer them a possible palliative intervention.

The wish to hasten death is a complex phenomenon of variable intensity, linked to physical and non-physical suffering, including loss of meaning and fear of being a burden13. In a recent Australian retrospective case series, among 141 patients interested in MAID, the initial request was motivated by the desire for autonomy (68%), by current suffering (57%), and by the fear of future suffering (51%); one third presented with depression or anxiety and half were in clinical-functional decline14. In the same case series, MAID could both strengthen and hinder the quality of palliative care, at times being chosen as an alternative to it, with difficulties in the care relationship14.

In Italy too, these will probably be the main dimensions of suffering to which palliative care will have to respond in patients oriented toward assisted suicide. When the person, although informed and taken into care, nonetheless chooses assisted suicide, the principle of non-abandonment will require that the care relationship not be interrupted5. Coexistence with the assisted suicide pathway, however difficult and grounded in distinct roles, is therefore a challenge that awaits Italian palliative care as well: addressing it will require knowledge of the scientific data, a basis for dialogue between positions that are often antithetical yet united by respect for the ill person and for those who care for them.

References

1. World Health Organization. National cancer control programmes: policies and managerial guidelines. 2nd ed. Geneva: WHO; 2002.

2. Gerson SM, Koksvik GH, Richards N, Materstvedt LJ, Clark D. The relationship of palliative care with assisted dying where assisted dying is lawful: a systematic scoping review of the literature. J Pain Symptom Manage 2020; 59: 1287-1303.

3. Chambaere K, Cohen J, Bernheim JL, Vander Stichele R, Deliens L. The European Association for Palliative Care White Paper on euthanasia and physician-assisted suicide: dodging responsibility. Palliat Med 2016; 30: 893-4.

4. Blanke CD, Corn BW, Ddungu H, et al. International end-of-life choices. Am Soc Clin Oncol Educ Book 2026; 46: e521004.

5. Società Italiana di Cure Palliative, Comitato per le Questioni Etiche (COMETE). Il rapporto tra le cure palliative e la richiesta di suicidio medicalmente assistito. Position paper SICP; 2026 Disponibile su: https://www.sicp.it/doc/position-paper-rapporto-CP-richiesta-SMA.pdf

6. Dierickx S, Deliens L, Cohen J, Chambaere K. Involvement of palliative care in euthanasia practice in a context of legalized euthanasia: a population-based mortality follow-back study. Palliat Med 2018; 32: 114-22.

7. Gamondi C, Borasio GD, Oliver P, Preston N, Payne S. Responses to assisted suicide requests: an interview study with Swiss palliative care physicians. BMJ Support Palliat Care 2019; 9: e7.

8. Radbruch L, Leget C, Bahr P, et al. Euthanasia and physician-assisted suicide: a white paper from the European Association for Palliative Care. Palliat Med 2016; 30: 104-16.

9. Chochinov HM, Fins JJ. Is medical assistance in dying part of palliative care? JAMA 2024; 332: 1137-8.

10. Downar J, MacDonald S, Buchman S. Medical assistance in dying and palliative care: shared trajectories. J Palliat Med 2023; 26: 896-9.

11. Patuzzo S, Pulice E, Orsi L. Palliative care against medically assisted death? Misunderstanding and instrumental objections. Am J Hosp Palliat Care 2024; 41: 853-8.

12. Riisfeldt TD. Euthanasia and assisted suicide are compatible with palliative care and are not rendered redundant by it. Camb Q Healthc Ethics 2023; 32: 254-62.

13. Rodríguez-Prat A, Pergolizzi D, Crespo I, et al. The wish to hasten death in patients with life-limiting conditions: a systematic overview. J Pain Symptom Manage 2024; 68: e91-e115.

14. Michael N, Jones D, Kernick L, Kissane D. Does voluntary assisted dying impact quality palliative care? A retrospective mixed-method study. BMJ Support Palliat Care 2025; doi:10.1136/spcare-2024-004946.

A note from the editors

Starting with the first issue of 2026 - in every issue - RICP has begun publishing some of its content in two languages, Italian and English, in both the print and digital versions. To ensure that each article is assigned a single DOI and to avoid duplicate content online, starting with this issue, the digital version - available at www.ricp.it - will include only the English text. The print version, however, will continue to be published in both languages (Italian and English).